Morbidity and mortality in very low birth weight infants

Original article
Arch Argent Pediatr 2012;110(5):394-402 / 394
Morbidity and mortality in very low birth
weight infants assisted in public hospitals
located in the city of Buenos Aires
Neonatal Network of Public Hospitals in the city of Buenos Aires*
SUMMARY
Introduction. The Neonatal Network of Public Hospitals in the city of Buenos Aires closely
monitors the progress of newborn infants with
a birth weight less than 1500 g (very low birth
weight, VLBW) because it largely contributes to
neonatal morbidity and mortality.
Objective. To analyze the morbidity and mortality of VLBW infants and determine their riskadjusted mortality using the score of the South
American Neonatal Network (Red Neonatal de
los países del Conosur de América, NEOCOSUR).
Material and Methods. Live infants born in the network hospitals with a birth weight of 500-1499 g
between 2008 and 2010 were included in the
study. Data was recorded prospectively using a
standardized methodology. Mortality, morbidity and risk-adjusted mortality rates according
to the NEOCOSUR score were estimated.
Results. There were 92,698 infants born during
the study period. Of them, 1.26% weighed less
than 1500 g at birth. Only 40.4% of these received
a full course of antenatal corticosteroids. A total
of 62.7% of these developed respiratory distress
syndrome, 5.4% enterocolitis, 10.1% intracranial
hemorrhage, and 13.4% severe retinopathy. Early
sepsis was observed in 5.6%, and late sepsis in
9.6%. Bronchopulmonary dysplasia was present in 10.7% of the cases. Neonatal mortality
was 29.2%, and the adjusted mortality with no
major malformations was 25.4%. Survival of infants with a birth weight of ≥750 g and a gestational age of ≥26 weeks was 50%. The observed/
expected mortality ratio was 1.04, with a large
variability.
Conclusions. The percentage of VLBW infants
who received antenatal corticosteroids was low.
The incidence of sepsis and the rate of infants with
severe retinopathy of prematurity are high. The
risk-adjusted mortality is higher than expected.
Key words: neonatal morbidity, neonatal mortality, very low birth weight newborn, risk-adjusted
mortality.
http://dx.doi.org/10.5546/aap.2012.394
Jorge Tavosnanskaa, Irene M. Carrerasb, Diana Fariñac, Guillermo Luchtenbergd,
María Luisa Celadillae, Marcela Celottof, Norma Ferreirog, Jorge Gonzálezh,
Isaac Groisi, Jorge Lamelasj, Mario Mardyksk, Abel Menalledl,
Mariana Panzittam, Noemí Petruccellin, Claudio Solanad, Luis Somarugao,
Sandra Caparrósi, Alberto Capriatan, Daniel Gangig, Nora Goyenecheh, Paula Molinaa,
Delia Nagelo, Juan Orsinij, Adriana L. Piñóni, Elio Rojasd, Liliana Roldána, Cecilia Rubiod,
Marta Russmannb and Mario Siniscalcoi.
E-mail:
Irene Mercedes
Carreras, MD:
[email protected]
Conflict of interests:
None.
Received: 12-20-2011
Approved: 5-4-2012
a. Hospital General de Agudos “Dr. J. A. Fernández”;
b. Hospital de Niños “Dr. R. Gutiérrez”;
c. Hospital Nacional de Pediatría “Prof. Dr. J. P. Garrahan”;
d. Hospital Maternoinfantil “R. Sardá”;
e. Hospital General de Agudos “Dr. T. Álvarez”;
f. Hospital General de Agudos “C. Argerich”;
g. Hospital General de Agudos “Donación F. Santojanni”;
h. Hospital General de Agudos “Dr. C. Durand”;
i. Hospital General de Agudos “J. A. Penna”;
j. Hospital General de Agudos “J. M. Ramos Mejía”;
k. Hospital General de Agudos “D. Vélez Sarsfield”;
l. Hospital de Pediatría “Dr. P. de Elizalde”;
m. Hospital General de Agudos “P. Piñero”;
n. Hospital General de Agudos “Dr. I. Pirovano”;
o. Hospital General de Agudos “B. Rivadavia”.
Buenos Aires, Argentina.
Morbidity and mortality in very low birth weight infants assisted in public hospitals located in the city of Buenos Aires / 395
INTRODUCTION
Infant mortality is one of the main indicators
of healthcare quality. The continuous surveillance
of this indicator is a useful tool to assess the outcome, intervene in a timely manner, adjust unwanted de-viations, set up priorities, and adapt
procedures and techniques.
Annually, approximately 30,000 infants are
born in public maternity hospitals in the city of
Buenos Aires. Of them, 1.26% weigh less than
1500 g.1 Though very low birth weight (VLBW)
infants represent a small group of newborns, they
account for 54% of neonatal mortality, require
longer length of stay in the hospital, are one of
the leading causes of disability, and result in a
very high cost of care. All these characteristics, in
addition to strategies that have a positive impact
on infants’ progress, turn this group into one that
requires close surveillance. Birth weight, however, is not the only determining factor of neonatal
mortality; hence, it is necessary to standardize
results by means of scores based on multiple factors that would allow to predict a risk-adjusted
mortality index.
In the city of Buenos Aires, there are 11 community maternity centers located in general hospitals, 1 mother and child hospital and 3 neonatal
intensive care units in children’s hospitals that are
part of the Neonatal Network of Public Hospitals
in the city of Buenos Aires. They are grouped in 4
healthcare regions, with a remarkable concentration in two of them, where 75% of VLBW infants
are assisted. Up to this moment, there is not a
classification based on the level of hospital complexity; consequently, newborn infant care is not
organized by regions. Since 2007, the network has
been closely monitoring VLBW infants’ morbidity
and mortality. To this aim, the network systematically gathers information about morbidity and
mortality on an ongoing basis, compares findings
to similar standards and proposes changes to improve morbidity and mortality. In this study findings gathered in the last three years are described
and analyzed.
OBJECTIVES
1. To analyze morbidity and mortality of VLBW
infants born in public hospitals that are part of
the Neonatal Network of Public Hospitals in
the city of Buenos Aires.
2. To assess the risk-adjusted mortality using the
NEOCOSUR neonatal network index.
MATERIAL AND METHODS
This was an observational, descriptive, prospective study conducted within the context of
the surveillance of morbidity and mortality of
VLBW infants in the public sector of the city of
Buenos Aires during 2008-2010. All live newborn
infants (NBIs) with a birth weight of 500-1499 g
born between January 1st, 2008 through December 31st, 2010 and registered in the network database (BDN 1.2) were included. Data anonymously
collected from medical records were entered in
each hospital’s database at the time of patient’s
discharge and then, after a thorough review, they
were submitted for processing on an Excel datasheet. Data was validated, checked and sent back
so that missing data were filled in.
Observed outcomes
Maternal outcomes: age in years, gestational age
in weeks by date of last menstrual period, number of visits, condition, antenatal corticosteroids
(at least one dose), type of delivery.
Neonatal-fetal outcomes: weight at birth and at
discharge, gestational age, Apgar score, use of
surfactants, major malformations, cause of death,
autopsy. Morbidity indicators: presence of respiratory distress syndrome (RDS); bronchopulmonary dysplasia (BPD) defined as supplemental
oxygen requirement during at least 28 days at 36
weeks of age; patent ductus arteriosus (PDA) with
an echocardiographic diameter over 1.5 mm; clinically suspected sepsis confirmed by blood culture
or cerebrospinal fluid culture before (early) or after (late) 72 hours of age; stage II A or higher necrotizing enterocolitis (NEC) according to Bell’s
staging criteria;2 grade III or higher intracranial
hemorrhage (ICH) diagnosed by ultrasound or at
autopsy; grade III or higher retinopathy of prematurity (ROP), considered a “plus” disease and/or
requiring laser treatment.
Discharge status outcome: dead or alive; morbidity; oxygen requirement; and type of feeding.
Continuous outcomes were expressed using
the mean and standard deviation values, or the
median, and minimum and maximum values.
Categorical outcomes are expressed in n and in
percentages. Annual specific, overall and malformation adjusted mortality rates were obtained immediately after birth, early or late as defined by
the WHO,3 as well as the annual incidence of morbidity outcomes. With the aim to evaluate overall
mortality, newborn infants referred to children’s
hospitals that were part of the neonatal network
were included. To analyze mortality per weight
396 / Arch Argent Pediatr 2012;110(5):394-402 / Original article
class, ranges of 250 g were used with inclusive
limits of 500 g to 1499 g. To define the causes of
death, the criteria used was that of a single leading cause of death. Infants born at <25 weeks of
gestation and/or with a birth weight of <750 g
were defined as extremely premature infants.
Expected mortality was established using the
NEOCOSUR* score, which estimates death likelihood of a VLBW infant based on the following
parameters: birth weight, gestational age, Apgar score at 1 minute after birth, life threatening
congenital malformations, use of prenatal corticosteroids, and sex. The score is obtained by
comparing the expected mortality to the observed
mortality, estimating their ratio. A score higher
than 1 means that it exceeds the expected figure
and a score lower than 1 means that it is inferior.4
To evaluate the NEOCOSUR score, and according
to its baseline development, no patients referred
to children’s hospitals were included. They account for 6.2% of the population. The statistical
analysis was conducted using the software EPI
Info version 3.3.2.
Ethical and legal issues
The study was performed in compliance with
health authorities and in the context of the morbidity and mortality surveillance of VLBW infants, implemented by the network, a healthcare
and epidemiological approach that is not subjected to procedures developed to protect subjects
that participate in studies.5 The network database
collects dissociated and anonymous data, and adheres to the Argentine Act 25,326 regarding personal data protection (sections 8 and 11).6
RESULTS
During the study period, 92,698 infants were
born in public hospitals of the city of Buenos Aires. Of them, 1.26% weighed <1500 g at birth. Out
of them, 1157 (99%) infants were recorded.
* The NEOCOSUR risk score assigns, at the time of birth, the
likelihood that a VLBW infant dies during hospital stay,
based on the following data: birth weight, gestational age,
Apgar score at 1 minute after birth, life-threatening congenital
malformations, prenatal corticosteroid administration, and
female sex. The sum of the probability of death of each
individual results in the probability of death of a patient
population. These six factors are statistically significant and
arise from the application of a multiple logistic regression
model with a stepwise procedure. The score is not adequate
for individual use.
Table 1 shows the main characteristics of the
population.
Table 2 shows annual morbidity and mortality rates. Neither birth weight group distribution
nor gestational age distribution had a significant variation. The neonatal mortality rate was
29.2%, and the adjusted mortality rate, excluding
malformations incompatible with life, was a 4%
lower; both rates remained stable over the study
period. Survival rate evolution per birth weight
and gestational age includes the group of infants
referred to other hospitals. It was observed that,
as of a weight of 750 g or a gestational age of 26
weeks, the survival rate is close to 50%. With a
birth weight over 1000 g, the survival rate is higher than 80%. Most deaths occurred during the first
week of age.
Figure 1 shows the risk-adjusted mortality index according to the NEOCOSUR score and indicates that the observed mortality is slightly higher
than the expected mortality, with a great variability among medical facilities, as described in Figure
2. It was observed that medical facility B, with the
biggest number of patients, has a favorable result,
only exceeded by medical facility L, with the lowest number of patients.
Table 1. Overall characteristics of newborn infants with a
birth weight of less than 1500 g, born in the public hospital
network of the city of Buenos Aires (2008-2010)
Total VLBW infants, n
Newborn infants recorded, n, (%)
Maternal age (years), mean (SD)
Maternal age (years), median
(maximum, minimum)
No control of pregnancy, n, %
2-3 visits during pregnancy, n, %
Multiple pregnancy (2-3 fetuses), n, %
Intrauterine growth restriction, n, %
Complete course of antenatal corticosteroids
Incomplete course of antenatal corticosteroids
Birth weight, mean (SD)
Gestational age, mean (SD)
Male sex, n (%)
Apgar at 1st minute ≤4, n (%)
Infants born by caesarean section, n, (%)
Malformations incompatible with life, n (%)
Major malformations, n (%)
1169
1157 99.0
26 (7)
22
425
669
171
257
467
141
1073
29
579
267
940
60
117
(46-13)
38.1
60
15.5
25.8
40.4
12.2
(295)
(4.4)
50.0
23.1
81.2
5.2
10.1
Morbidity and mortality in very low birth weight infants assisted in public hospitals located in the city of Buenos Aires / 397
DISCUSSION
The assessment of healthcare based on the
surveillance of mortality indicators is not enough
because the aim is that newborn infants are discharged alive and also that they survive with minor consequences or no consequences at all. This
approach requires to monitor other outcome variables in addition to mortality, carry out infants’
Table 3 shows a comparison of our results with
those of NEOCOSUR.7,8 Extremely premature infants and RDS were the most common causes
of death (35% and 32%, respectively). Sepsis accounts for 19% and major congenital malformations account for 14%.
Causes of death per age at death are shown
in Figure 3.
Table 2. Annual morbidity and mortality of newborn infants with a birth weight of less than 1500 g
Total NBIs, n
Weight, mean (SD)
Gestational age, mean (SD)
Newborn infants recorded, n, (%)
Survivors, n (%)
Newborn infants referred to other hospitals, n, (%) Male sex, n (%)
Apgar at 1st minute ≤4, n (%)
Infants born by caesarean section, n, (%) Malformations incompatible with life, n (%)
Major malformations, n (%) 2008
409
(296)
(4.4)
97.1
68.9
7.1
54.4
23.4
83.9
4.0
10.3
1070
29
397
282
28
216
93
333
16
41
2009
2010
Total 08/10
374
1079 (285)
29
(3.2)
374 100.0
253
67.6
22
5.9
194
51.9
95
25.4
299
79.9
19
5.1
36
9.6
386
1097 (286)
29
(3.2)
386
100.0
259
67.1
22
5.7
169
43.8
79
20.5
308
79.8
25
6.5
40
10.4
1169
1073
(295)
29
(4.4)
1157
99.0
794
67.9
72
6.2
579
50.0
267
23.1
940
81.2
60
5.2
117
10.1
Mortality
n
%n
% n
%n
%
Overall mortality
127
31.1121
32.4 127
32.9375
32.1
Neonatal mortality (NM)
114
27.9
117
31.3
117
30.3
341
29.2
Early NM
83 20.3 8522.7 9424.4 26222.4
Death in delivery room
17
4.2
19
5.1
14
3.6
50
4.3
Late NM
31 7.6 328.6 236.0 1089.2
NM with no malformations incompatible with life
98
25.0
98
27.6
92
25.5
281
25.4
Post-natal mortality
133.2 41.1 102.6 34 2.9
NM per birth weight group (%) 500-749 g
60/76 78.9
41/56 73.2
50/59 84.7
151/191 79.1
750-999 g
39/90 43.3
93/93 44.1
38/77 49.4
118/260 45.4
1000-1249 g
16/10016.0 29/9430.9 23/99 23.2 68/293 23.2
1250-1499 g
12/143 8.4
10/131 7.6
16/151 10.6
38/425 8.9
NM per GA group in weeks (%) 20-24 weeks
21/21 100.0
6/7
85.7
20/23 87.0
47/51 92.2
25-28 weeks
48/118 40.7 54/13440.3 52/12342.3 154/37541.1
29-32 weeks
15/160 9.4
26/148 17.6
18/148 12.2
59/456 12.9
33-36 weeks
5/59
8.5
4/49
8.2
4/57
7.0
13/165 7.9
Morbidity
Complete course of antenatal corticosteroids
Incomplete course of antenatal corticosteroids
RDS
NEC
Early sepsis
Late sepsis
Grade III/IV ICH
Retinopathy* with laser treatment requirement
BPD, Mild
Moderate Severe
n
%n
% n
%n
%
165
41.6
147
39.3
155
40.2
467
40.4
46
11.6
41
11.0
54
14.0
141
12.2
238
59.9249
66.6 238
61.7725
62.7
20
5.022
5.9 20
5.262
5.4
16
4.0
10
2.7
39
10.1
65
5.6
27
6.8
15
4.0
69
17.9
111
9.6
44
10.8
36
9.6
38
9.8
118
10.1
32
11.3
48
19.0
26
10.0
106
13.4
16
5.714
5.5 14
5.444
4.0
26
9.3
29
11.5
8
3.11
63
5.7
24
8.515
5.9 16
6.255
5.0
*: percentage of survivors with grade III or IV ROP or with plus disease.
398 / Arch Argent Pediatr 2012;110(5):394-402 / Original article
follow-up, record data, and measure mid- and
long-term results. The review of records organized in databases provides accurate information
to identify processes and difficulties that need to
be improved, in order to facilitate the decision
making and strategic planning of improvement
processes.9
The creation of neonatal care networks enables
the implementation of strategies to improve quality.10,11 The Neonatal Network of Public Hospitals
in the city of Buenos Aires was created to meet the
need to find mechanisms to improve neonatal care
through the collaboration among its members. Its
primary objectives are: to assess the situation of
Figure 1. Annual risk-adjusted mortality of newborns with a birth weight of less than 1500 g in public hospitals in the city of
Buenos Aires (2008-2010)
References: O/E mortality: observed/expected mortality according to NEOCOSUR score; CI: confidence interval.
Figure 2. Risk-adjusted mortality of newborn infants with a birth weight of less than 1500 g in public hospitals of the city of
Buenos Aires per medical facility (2008-2010)
References: L, B, E, H, G, K, D, C, F, A, J: Hospitals participating in the Neonatal Network of Buenos Aires. O/E: ratio between the
number of observed deaths and number of expected deaths according to the NEOCOSUR score; CI: confidence interval.
Morbidity and mortality in very low birth weight infants assisted in public hospitals located in the city of Buenos Aires / 399
neonatal care, improve records, develop and maintain a database, report results, update guidelines
for care and provide recommendations targeted
at reducing neonatal morbidity and mortality. In
this context, the priority of the network is to publish its results and compare them to those of other
networks with similar population characteristics,
such as NEOCOSUR.
The comparison (Table 2) indicates that both
populations share basic characteristics. However,
in infants born within the studied network the use
of corticosteroids was lower and a c-section rate
was higher. RDS had an incidence of 65.4%, which
was lower than that of NEOCOSUR (73.3%),12 in
spite of the less frequent use of corticosteroids. It
has been widely shown that the antenatal use of
corticosteroids reduces the risk of RDS and the
use of resources.13,14 In our population, however,
the percentage that received a complete course of
corticosteroids remains at 40.4%, a rate lower than
that of other networks.15,16 This difference might
be related to under-recording.
Table 3. Morbidity and mortality rates of newborn infants with a birth weight of less than 1500 g in the Neonatal Network
of Public Hospitals in the city of Buenos Aires compared to those of NEOCOSUR
Period
Total (n) NBIs recorded (n) Weight in grams (mean, SD) GA in weeks (mean, SD) Female sex (%) Apgar score <4 at 1st min (%) Complete course of antenatal corticosteroids (%) Birth by cesarean section (%) Apgar lower than 4 at 1st min (%) Deaths; % (n) Overall neonatal mortality with no FSP (%) Death in the delivery room (%) Buenos Aires
NEOCOSUR
2008/102001/91
1169
10,258
1157
10,447
1073 (± 295)
1086 (± 279)
29 (± 4.4)
29 (± 3)
49.7
48.8
23.1
22.9
40.4
74.0
81.2
68.7
23.1
22.9
30.5 (357)
21.8 (2230)
23.4
21.5
4.5
3.4
62.7
10.2
11.9
14.1
13.4
5.6
9.6
71.3
10.6
11.1
24.6
5.9
3.8
19.3
Mortality per weight group (%)
500-750 g 750-1000 g 1000-1250 g 1250-1500 g 2008/10
78.5
40.8
18.8
5.9
2008/92
71.1
30.8
15.4
7.9
Mortality per GA group (%)
20-24 weeks 25-28 weeks 29-32 weeks 33-36 weeks 2008/102008/93
92.2
84.7
41.1
32.6
12.9
9.8
7.9
11.0
Morbidity
Respiratory distress syndrome (%) Grade III-IV intracranial hemorrhage (%) Necrotizing enterocolitis (%) Bronchopulmonary dysplasia (%) Grade III-IV retinopathy (%) Early sepsis (%) Late sepsis (%) References: NBIs: newborn infants; GA: gestational age. Buenos Aires: Buenos Aires group.
Sources:
- D’apremont I, Tapia JL, Villarroel L. and Neocosur Collaborative Group. 10 años de funcionamiento de una red sudamericana. Resultados perinatales. Resumen del IV Congreso Chileno de Neonatología. Santiago de Chile, October 2010. Available at:
http://sistemas.med.puc.cl/neocosur/ingles/neocosur.asp.
- Grandi C, Rojas E, Solana C, Larguía M. Estadísticas Neocosur, Hospital Materno Infantil “Ramón Sardá”, 2009. Rev Hosp Mat
Inf Ramón Sardá 2010: 29(4)171-177.
- Grandi C, Rojas E, Solana C, Larguía M. Estadísticas Neocosur, Hospital Materno Infantil “Ramón Sardá”, 2010. Rev Hosp Mat
Inf Ramón Sardá 2011;30(4)176-180.
400 / Arch Argent Pediatr 2012;110(5):394-402 / Original article
Although more immature groups have a lower
survival rate, the number of children with severe
ROP was high (13.4%), and well above to that of
NEOCOSUR (5.9%). This is likely related to the
availability of healthcare resources, both technical and human.
Among the other studied outcome variables,
the lower rate of BPD and late sepsis should be
pointed out, which is consistent with the lower
rate of neonatal survival in small and immature
infants. It is a known fact that there are great differences in sepsis rates from the different neonatal
networks and among different hospitals. In this
network, the rate of sepsis apparently increased
during the follow-up period, reaching 10.1% (early sepsis) and 18% (late sepsis) in the last period,
probably due to under-recording. If we consider that infants who died during the first week of
age were not excluded, this percentage is high.
The sum of both factors leads to working on the
management of this severe situation which, additionally, is the cause of death in 20% of infants
who died. In order to improve these results, it
might be necessary to be determined and to disseminate practices with sound and widely proven benefits.17-19
Neonatal mortality of VLBW infants in hospitals in the city of Buenos Aires is higher than that
of NEOCOSUR in all weight and gestational age
groups, except in the ranges of 1250-1499 g and
33-36 weeks, and is lower than the percentages
reported by the Ministry of Health for the entire
country (39.9% and 42% in 2006 and 2010, respectively).20,21
Birth weight is a major determining factor of
neonatal mortality, but does not explain its great
variability. Medlock has recently conducted a revision of mortality prediction models for VLBW
infants. Medlock concluded that multivariate
models may offer a better prediction than birth
weight or gestational age alone, although it is
necessary to conduct additional research with
validation and impact studies.22 The NEOCOSUR
network developed a relatively simple model to
predict death in VLBW infants, that was selected to estimate the risk-adjusted mortality in this
study. It was observed that nosocomial mortality
in VLBW infants in public hospitals in the city of
Buenos Aires is 4% higher than expected, with
great variability among medical facilities (Figure 2). The study identified hospitals with a low
number of patients with mortality lower than ex-
Figure 3. Causes of death of infants with a birth weight of less than 1500 g in public hospitals in the city of Buenos Aires,
according to the age at death (2008-2010)
References: Early NM: early neonatal mortality; late NM: late neonatal mortality;
Post-natal M: post-natal mortality;.
Morbidity and mortality in very low birth weight infants assisted in public hospitals located in the city of Buenos Aires / 401
pected, and hospitals with a high number of patients with mortality higher than expected. This
is consistent with the study conducted by the
Vermont Oxford Neonatal Network,9 published
by Rogowsky in 2006. In this study, the conclusion was that indirect quality indicators, such as
the number of patients, are not adequate predictors of mortality, and that direct indicators, which
are based in outcome measures, are much more
reliable. In addition, the study emphasizes the
importance of developing databases that allow
gathering detailed information about the processes and results, and of identifying and reporting
those that result beneficial.
The gap noted when comparing our results
with those obtained by other networks remains
a great challenge for public policies in this area.
Some of the determining factors of unfavorable
results in the studied group are: population social
and economic factors (poverty, education, access
to healthcare), healthcare-related factors (resources and their distribution), and factors related to
the health team (number, training and attitude).
Of these, the leading factors are nurse staffing
deficits23-25 and the absence of a region-oriented
framework that favors resource improvement and
equality for this vulnerable group of infants.26,27
In relation to the first factor, Hamilton (United Kingdom) proved that risk-adjusted neonatal
mortality was not related to the size or type of
the care unit, but to the availability of specialized
nurses. A higher number of specialized nurses
taking care of premature infants reduces risk-adjusted neonatal mortality.23 The NEOCOSUR collaborative group has recently published a study
showing that neonatal results are associated with
the activity and level of professionals, specially
nurses and assistants.26 Lack of this resource in
Argentina is a well-known issue, and should become a priority for health public policies. Increasing the number of specialized nurses in neonatal
intensive care units may enhance survival of premature infants or very low birth weight infants.
In relation to the second factor, the network
promoted the approval by the Ministry of Health
of Resolution 1137. This resolution established,
in July 2011, the regionalization of neonatal care
for VLBW infants in public hospitals in the city of
Buenos Aires, set the following hospitals as points
of reference: “Cosme Argerich“, “Carlos Durand“,
“Juan A. Fernández“, “Donación Santojanni“ and
“Ramón Sardá“, and approved the referral procedure for labor when it occurs before reaching
32 weeks of gestation.28 This last item is yet to be
implemented given the low number of nurse staff
to cover the quota required by the resolution. It
is expected that this resolution will reduce the inequality undergone by very low birth weight infants when they are born in a hospital that may
have better o worse results.
Efforts should also be directed towards changing attitudes and practice according to the resources provided by scientific evidence, which
include social-economic improvement and parent’s education,29 regionalization of healthcare,
including neonatal and perinatal care, adequate
control of pregnancy, an appropriate number of
qualified human resources, adequate care during
labor and for the newborn, correct resuscitation
measures, timely provision of intensive care, and
humanized assistance.30 This is a challenge for creativity and for the actions of all the members in
the network and of the health authorities in order
to obtain better results through the implementation of healthcare policies and models that will
overcome the limitations found by previous policies, which had intrinsic weaknesses.
CONCLUSIONS
• Neonatal mortality during the study period
was 29.2%.
• Sepsis is the cause of death in 20% of cases.
• The percentage of VLBW infants that received
a complete course of corticosteroids is low;
however, RDS occurred in 62% of the cases.
• The incidence of sepsis and the rate of infants
with severe ROP are high.
• Risk-adjusted nosocomial mortality is 4%
higher than expected, and presents great variability among the different medical facilities in
the network.
Acknowledgements
To the Technical Department of Hospital Materno Infantil “Ramón Sardá” for their help with
IT, to Dr. Marina Brussa for her collaboration in
retinopathy of prematurity surveillance, to Dr.
Celia Lomuto and Prof. Dr. Miguel Larguía for
their valuable input and feedback, and for reviewing the draft. n
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